ey Ze WELLE. ZZ ZZ iy 5 CORNELL UNIVERSITY. THE Roswell P. Flower Library THE GIFT OF ROSWELL P. FLOWER FOR THE USE OF THEN. Y. STATE VETERINARY COLLEGE 1897 8394-1 wii Cornell University Library The original of this book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924021949320 Veterinary Mepicine Serims No. 1 SPRINGTIME SURGERY Edited by D. M. Campbell, D.V.S. Editor, American Journal of Veterinary Medicine THIRD EDITION / / REVISED AND ENLARGED Chicago American Journal of Veterinary Medicine 1913 Copyright, 1913 D. M. Campbell The Rajput Press, Chicago PREFACE TO THIRD EDITION Advantage has been taken of the exhaustion of the last edition to correct afew typographical errors and, at the suggestion of the authors, to make slight changes in some of the articles. The remarkable sale of this work has made necessary the third edition, within a year from the date of its first publication. There are many evidences that it has proven helpful to a large number of veterinarians and that this edition will meet with the cordial response given its predecessors. THE EDITOR. Chicago, March 1913. Veterinary Medicine Series No. 1 PREFACE TO SECOND EDITION The fact that a second edition, of a veterinary publication, should be required, within thirty days from the time the first edition was received from the bindery—thus establishing a new record among veterinary publications—is proof positive of its usefulness and its welcome. SPRINGTIME SURGERY has had this remarkable sale. A higher commendation is scarcely possible, a further one unnecessary. This work is unique, an innovation in veterinary literature, and has appealed strongly to practis- ing veterinarians. The thanks of the editor, and all credit for the usefulness of SPRINGTIME SUR- GERY, are due to the contributors who have given of their time and talents for the enlightenment of the Profession. Three articles have been included in this that are not contained in the former edition, two in the former have been omitted from this edition. A number of those in the first edition have been thoroughly revised for this one by the authors. THE EDITOR. Chicago, April, 1912. SUCCESS Pluck will win—its average is sure, He wins the fight who can the most endure. Who faces issues, he who never shirks, Who waits and watches and who always works. (Author unknown). PREFACE TO FIRST EDITION There is an obvious advantage in having grouped, in one small volume, really meritorious discussions of the cases most common at any season. The articles in this book, which are re- printed from the American Journal of Veteri- nary Medicine, constitute, we believe, the most instructive yet brief description, and the most helpful case-reports to be gleaned from the liter- ature on the surgical and obstetric problems com- mon during the foaling and castrating season. The discussions of “Springtime Surgery,” while in no sense exhaustive, yet constitute, for the practising veterinarian, a valuable supplement to the standard textbooks of veterinary surgery and obstetrics. The superior merit of these articles amply justifies their reproduction in a form more per- manent than is offered by magazine publication. The frequent requests from subscribers for copies of the issues of “Veterinary Medicine” containing various of these articles convinces us, that their presentation in book form will be wel- comed by a large number of veterinarians and that this volume will be of much usefulness in this field. THE EDITOR. Chicago, March, 1912. TABLE OF CONTENTS Castration of Cryptorchids ....J..00e..... 9 Practical Methods of Cryptorchidectomy. . sag. : Cryptorchidectomy in Horses «).!. sila... 15 An Interesting Monorchid +3: 3 $2¢..... 83 A Castrator’s Error .~..: Pes Aug Mee aries 87 Hemorrhage After Castration Wi\0oe.e.208. 91 Castration of Pigs Having Scrotal Hernia?! .¢ 93 Operation on a Hermaphrodite2.!).cesesi... 97 Spaying Heifers on Western Ranches‘ :WhbradO1 Oophorectomy in Cats Fs. Sawiii cee cee es 111 Prolapsus Uteri: Its aie Treatment. .113 Unusual Case of Obstetrics 7. ....: Sig are ity 116 Proper Replacement of the Everted Uterus. .117 Pervious Urachus 20)! Uc. cece cence 120 Care of Navels in Newborn '.; 3's); ae oer 123 Superfetation with ah of a Casefeu.6: 188 Atvasig hil dc. fae bie cecesvercecesa es 137 Treatment of Contracted Tendons in Foals. ..1415 Minor Means of Restraint’ ol ace Pes ithe ere 145 Castration of Cryptorchids’ By W. L. WILLIAMS, V. S., Professor of Surgery and Obstetrics in the New York State Veterinary College, Cornell University, Ithaca, New York, author of “Veterinary Obstetrics,” “Surgical and Obstetric Operations,” etc. It is generally considered advisable to castrate’ all male domestic animals which are to be regu- larly used for work or as human food. However true this may be of normal males, it is empha- sized in most cases of cryptorchids or hidden testes. It is especially desirable that the cryptorchid, or the monorchid, be castrated, in order that he may not be used for breeding purposes, because he may largely transmit the defect to his off- spring. In addition to this, the abdominal testicle usually induces a perverted sexual desire, closely analogous to the nymphomania of the female. *Reprinted from the Missouri Valley Veterinary Bulletin, April, 1910. 10 SPRINGTIME SURGERY Etiology—The causes of cryptorchidy are various, and are not wholly understood. We meet with three groups of causes or conditions which are of interest: 1. Arrested development, or descent of the organ. 2. Aberration of the development of the organ —teratoma. . 8. Pathologic conditions of the testes. In the first case, the testicle forms normally, and drops from its embryonic location into the peritoneal cavity, but fails to descend into the scrotum. It then retains its fetal character, is small, soft, flaccid and histologically shows the fetal spermatoblasts, but no spermatozoa. The gland is therefore without procreative function, but induces often a sexual mania. Its position varies, being located at any point on a line pass- ing from the embryonic seat, near the posterior end of the kidney, to and into the internal in guinal ring. The second class, the teratoma, comprises a widely varying group of dermoid cysts, of al- most any dimensions and containing epidermal CASTRATION OF CRYPTORCHIDS 11 debris and structures, such as hair, dental tissues, etc. They are highly interesting because they suggest that the sexual glands are really of epi- blastic origin, as contended by some embryolo- gists, instead of mesoblastic, as asserted by most authorities. The third group comprises extremely variable pathologic changes, such as cystic, calcareous or other forms of degeneration, malignant new- growths, etc. These three groups are known to be of very unequal size, though definite data as to the pro- portions of each are wanting. Ninety-one cases have been operated upon in our clinic, of which ninety belonged to the first group, none to the second, and one to the third. In private practice we have met with one additional case of patho- logic testicle, but no teratoma. The teratoma are considered so unusual that they are largely recorded, and probably an ex- aggerated idea of their prevalence is acquired. It is highly important that these three classes be kept in mind, since they have an essential bear- ing upon the surgical procedure in castration. 12 SPRINGTIME SURGERY Other less essential elements entering into the surgical problem of cryptorchidy are whether the . testicle is abdominal or inguinal in location, and to what species the animal belongs. Cryptorchid castration, like many surgical pro- cedures, was at first chiefly empiric in character, and in fact is still largely practiced as an empiric operation, the operation being largely taught and learned in a manner devoid of scientific knowl- edge. Preparation.—The preparation of an animal for the cryptorchid operation does not differ ma- terially from the general rule for other abdominal operations. We desire that the patient shall be in prime physical condition, having had abundant exercise or work to place him in good, vigorous health. Before the operation, the alimentary tract should be emptied either by restricted diet or by hypodermic catharsis. Fullness of the alimen- tary tract should be obviated for general surgical reasons and for the special purpose of facilitating the operation, by affording greater intra-abdomi- nal room and preventing prolapse of abdominal viscera through the wound. CASTRATION OF CRYPTORCHIDS 13 Control—The securing of the patient, in case of the horse, needs be either in dorsal recum- bency, or in the lateral position, with that side upon which the hidden testicle is located, upper- most. There is but one essential detail in secur- ing the horse: The thigh on the side of the hid- den testicle must be fully abducted. This may be effectively accomplished by many methods of cast- ing, and may be perfectly attained upon some types of operating table. If the thigh is not completely abducted, the operator may find his hand so compressed that it is soon fatigued and disabled, and the operator confused and lost. It is a great error to attempt the operation except this abduction is complete and secure. Should the apparatus slip during the operation, and the operator’s hand become com- pressed, it is liable to greatly confuse even an ex- perienced surgeon. The question of general anesthesia is one upon which operators may justly differ. For the be- ginner, it is the best way. The beginner may, under proper aseptic precautions, manipulate an anesthetized cryptorchid for half an hour or an 14. SPRINGTIME SURGERY hour, without serious harm to the patient, and without seriously transgressing the general senti- ment of humanity for animals, which is develop- ing so rapidly amongst our people. Anesthesia is also highly important for the experienced opera- tor. The inguinal region needs to be kept as freely open and the tissues as passive as possible, this can be attained only by general anesthesia. When the beginner is working upon an anes- thetized patient, he is relieved from the dis- turbances of change in position and the shifting in the relations of parts. The abdominal viscera are not forcibly pushed against his hand or through the opening. It is of great importance also that the beginner should be relieved, through the general anesthesia of his patient, from the confusing and enervating mental anxiety caused by the pain he is otherwise inflicting upon the pa- tient, as expressed by violent struggling, sweat- ing, groaning, etc. Again, general anesthesia is always best, even for the experienced operator in all cases of com- plications, and the surgeon rarely knows that a case is complicated until deeply in the operation, CASTRATION OF CRYPTORCHIDS 15 where he cannot retreat or readily modify his plans. We believe in general anesthesia in all cases, Diagnosis—Some advise rectal exploration prior to securing the patient for operation. The procedure has certain value. In those cases of monorchidy where the scrotal testicle has been removed (a very unfortunate and inadvisable procedure), the operator may determine definitely upon which side the hidden testicle is located. It may further give him important information as to whether the retained gland falls within our first, second, or third class. Should it belong to the second or third class, the examination reveals to the operator the nature of the conditions, fore- warns him of the obstacle to be overcome, and en- ables him to plan his operation. : On the whole, rectal exploration prior to opera- tion is largely impracticable. It is generally in- convenient to make such examination until im- mediately prior to the operation, and at that time, it is as a rule imprudent because of the difficulty of cleansing the hands properly after they have been soiled by feces. 16 SPRINGTIME SURGERY Asepsis and Disinfection—Another point of very great importance is the question of dis- infection of the operative area, and the main- tenance of asepsis. The problem is somewhat alike, whether the incision be made in the scro- tal, inguinal, prepubian or flank region. In the horse, the incision is usually made in the scrotal or inguinal region, while in other animals it is best made in the upper flank. While the skin of the scrotal and inguinal regions is very thin, soft, and usually almost hairless, it is nevertheless . thickly covered with sebum, which is very insolu- ble and difficult to remove. Washing for a few minutes with any ordinary antiseptic, even though preceded by soap and warm water, is of scant, if any value. The problem of the practical dis- infection of this region has not been solved. The profuse application of alcoholic or ethereal solu- tions excoriate the delicate skin. Careful investigations need be made toward solving this problem. Possibly a good method would be to wash the parts thoroughly, an hour or two prior to the operation, with.soap and hot water, perhaps mixed with kerosene in emulsion, CASTRATION OF CRYPTORCHIDS 17 or with lysol, bacterol, or carbolic acid. The sheath being always dirty bacteriologically, the smegma from this should be carefully cleared away, and the sheath and prepuce anointed with an antiseptic oil, glycerin or vaseline. The skin having been allowed to dry completely, when the patient is secured for the operation, the opera- tive area may be liberally covered with tincture of iodine, and allowed to dry before making the incision. After the skin incision has been made, additional security might be attained by again applying the tincture of iodine to the margins of the cutaneous wound. Incision——Some operators make their incision through the skin and dartos in the scrotal region, parallel to the median raphe and one to two inches laterally therefrom. Others make their incision directly over the external inguinal ring and in the same direction. By the first method, the operator inserts his hand through the wound in the skin and dartos, divides the loose areolar connective tissue and pushes aside the numerous vessels, in an upward. and outward direction until he reaches the external inguinal ring immediately at that 18 SPRINGTIME SURGERY point at which the second operator would make his incision. - The incision over the external ring is therefore more direct and the resulting wound less exten- sive, in which respect it is more conservative and preferable. The scrotal incision has the impor- tant advantage over the inguinal, in that the in- evitable movements of the thigh after the opera- tion disturb the cutaneous wound over the inguinal ring, but do not seriously involve the scrotal wound. We prefer the scrotal incision. Inguinal Cryptorchidism. —- Having reached the loose areolar tissue in the external abdomi- nal ring, whether indirectly through a scrotal in- cision or directly through an inguinal wound, the operator, with his fingers in the form of a cone, and by means of a rotary motion, pushes the areolar tissues aside and cautiously advances his hand upwards, outwards and slightly forwards toward the internal inguinal ring, or the position which it should occupy. Care should be taken to note here the presence or absence of a dis- tinguishable gubernaculum testis, of the epididy- mis or of the testicle itself. CASTRATION OF CRYPTORCHIDS 19 If a recognizable gubernaculum is present, it may be an important guide to the internal ring, and hence an aid of value to the operator, especi- ally to the beginner; or the operator, by grasping this and drawing upon it, may bring the testicle out through the ring and grasp it. Usually the presence or absence of this structure in a recog- nizable form may be suspected by the presence or absence of a distinct dimple or depression at the fundus of the scrotum. When the epididymis has descended into the scrotum, it is recognized as a somewhat firm cord about the size of a man’s finger, and is well nigh indistinguishable from the stump of the sper- matic cord following castration. It is more free from adhesions to surrounding tissues, and its obtuse extremity is connected with the skin and dartos only by the indistinct gubernaculum. Cut- ting through the peritoneal sheath of the cord, the operator exposes the vas deferens and tail of the epididymis firmly attached, naturally, not by adhesions, at the distal end of the tubular cord. By exerting traction upon the tail of the epididy- mis, the head of that organ may be brought into 20 SPRINGTIME SURGERY view, the entire epididymis being abnormally elongated and attenuated. The testicle itself re- mains firmly lodged above the internal ring, or incarcerated in it, and, however much traction may be exerted on the epididymis, the gland usually remains immovably fixed. The first case of this kind with which we met led us into error, and we removed the epididymis and a portion of the vas deferens, while we left the testicle in the abdomen. Later in our clinic we operated upon a case, the history of which could not be traced, but which had evidently been operated upon by some one who had fallen into the same error, removing the epididymis and leaving the testicle. The condition offers some difficulty to overcome. The most direct method is to freely incise the peritoneal sheath down to the internal ring and either dilate this by forcing the finger through the ring along side of the vas de- ferens and epididymis, or by cautiously incising the ring with a scalpel or bistoury. The testicle may then be withdrawn and removed. If the testicle itself is encountered in this re- gion (inguinal cryptorchidism) the gland is to be CASTRATION OF CRYPTORCHIDS 21 seized and forcibly brought out through the wound. Having passed through the internal ring, the gland is covered by the cremasteric fascia or tendon and by the parietal peritoneum, which are to be incised as soon as brought to view, and the testicle laid bare. It is to be noted that in all cases of abdominal cryptorchidism, including those we have mentioned where the epididymis has descended into the scrotum, the testicle, when brought out, is naked; while in inguinal cryptor- chidism, the testicle is inevitably brought out covered by the cremasteric structures and the parietal peritoneum. Locating the Internal Inguinal Ring.— Encountering neither gubernaculum, epididymis or testicle in the inguinal region, the operator should search for and locate the internal abdom- inal ring, whether he designs to penetrate it or not, as it constitutes the immediate, logical guide to the location of the testicle. This ring may usually be recognized in the eryptorchid horse, as an elliptical slit, appearing to the touch as about three-fourths to one and one-fourth inches long by one-half inch wide, 22 SPRINGTIME SURGERY directed obliquely forward and outward in its greater diameter. It is covered by a thin layer of peritoneum, while its margins, the borders of the great and small oblique muscles, are distin- guished by their greater thickness and firmness. This ring is located two to four inches upward, outward and slightly forward from the external abdominal ring. It is just opposite and very near to the crural ring, and, by palpating outward against the thigh, the operator easily recognizes the pulsating femoral artery as it emerges from the crural ring. In some cases the internal ring is unrecog- nizable by palpation, but the determination of its approximate location is nevertheless essential to scientific cryptorchid castration. The recog- nition of the ring is especially difficult in animals previously operated upon unsuccessfully, and fol- lowed by the formation of a large amount of dense, cicatricial tissue. When the ring has been recognized, if the operator will approximate his thumb, index, and second fingers to constitute an incomplete circle of one to two inches in diameter and press the ends of the digits against the abdom- CASTRATION OF CRYPTORCHIDS 23 inal muscles about the margins of the ring, the peritoneal curtain closing the ring, the processus vaginalis, tends to push outward in the form of an obtuse cone, while enclosed within it are the gubernaculum and usually the tail of the epididy- mis and the base of the vas deferens. The guber- naculum, in its intra-abdominal position, is recog- nized, as a somewhat distinct, firm, straight cord, about one-eighth of an inch in diameter, some- what movable within the peritoneum. The two latter are recognizable as hard dense, coiled cords or filaments, which are readily grasped beween the thumb and fingers, and clearly recognized by palpation. Securing the Testicle— These facts we have found of the greatest importance in the clinical teaching of the operation. It is the keynote in our method of instruction. We advance the operation to this point, seize the processus vagin- alis enclosing the gubernaculum, the vas deferens or the tail of the epididymis between the thumb and fingers, introduce a long pair of forceps, and seize the gubernaculum, epididymis or vas defer- ens, still covered by the peritoneum. We then 24 SPRINGTIME SURGERY secure the forceps in this position, with the de- sired structure firmly caught, and the beginner introduces his hand, palpates all the parts, rup- tures the peritoneum, grasps the gubernaculum . and then the vas deferens, followed by the epi- didymis, and completes the operation. Reaching and recognizing the internal ring, operators divide themselves into two or more groups in their further procedure. We recommend, in those cases we have just mentioned, in which the operator can grasp the vas deferens or epididymis outside the ring in the processus vaginalis, still covered by the perito- neum, that the peritoneal covering be ruptured by dragging upon it, the tail of the epididymis grasped and drawn out and the testicle itself brought out by traction upon the epididymis, thus completing the operation without the insertion of the hand or even of a finger into the abdominal cavity. In some cases, the testicle may not be drawn through the narrow ring by traction alone, in which instances we insert an index finger, dilate the ring, and, exerting traction on the epi- CASTRATION OF CRYPTORCHIDS 25 didymis with the other hand,, guide the gland through the ring with the introduced finger. Should we be unable to grasp the epididymis outside the ring, we penetrate the ring with an index finger, and, directing it backward, hook the index finger over the gubernaculum as it leaves the posterior margin of the ring, to immediately lose itself in the tail of the epididymis. This is grasped, drawn through the ring, and the opera- tion then proceeds as before. Should the operator fail to locate the ring, he needs at least to determine its approximate loca- tion, penetrate the muscular wall as near to the normal position of the ring as he can determine with his index finger, and, palpating the surface of the peritoneum, locate and grasp the guberna- culum, and eventually the vas deferens. Theoretically, should the operator fail to locate the testicle by this plan, he should next introduce the entire hand into the peritoneal cavity, again search for the gubernaculum, the epididymis, and especially for the gland itself, and as a final re- sort search for the vas deferens about the urethra and trace it back to the gland. 26 SPRINGTIME SURGERY Practically, when an operator must insert his entire hand into the abdominal cavity in his search for the testicle, it is the operator, and not the tes- ticle, which is lost, with often a far too poor pros- pect of finding himself and recognizing the defi- nitely located and attached organ. Too many operators, and especially beginners, search for, and attempt to identify the testicle, without considering the relations to the gland of the gubernaculum and vas deferens. Searching independently of these for the gland is like a shore fisherman on a dark night, who has securely hooked and landed a fish in the darkness, and starts groping about to find it, instead of follow- ing his pole to the line, and thence along the line to the hook, where the fish is definitely fixed and located. So, in castrating a cryptorchid, the tes- ticle need not be “found” in the common mean- ing of the word, because it is not “lost,” for the epididymis and vas deferens are definitely and closely moored at the posterior commissure of the internal ring by the gubernaculum and at the proximal end of the epididymis, securely fixed, is the gland itself. CASTRATION OF CRYPTORCHIDS 27 Going back to the course of the operation, when the operator has reached the internal ring or its immediate vicinity, many operators diverge from the technic we have recommended. Instead of penetrating the ring, they push somewhat upward and forward and penetrate the fascia of the small oblique muscle. By this plan, the insertion of at least one finger in the abdom- inal cavity is necessitated, which, by the direct method we have suggested, may be obviated. Be- yond this, the operation is identical. It is, we believe, erroneously contended by the advocates of this plan that prolapse of the abdom- inal viscera is thereby obviated. The only cases of visceral prolapse from cryptorchid castration observed in our clinic have been patients operated upon by experienced castrators who were uncom- promising devotees to this plan, and applied the technic in their operations. In the ordinary cryptorchid castration, where the testicle is small and flaccid, and where it is drawn through the ring by traction on the vas deferens and epididymis or the withdrawal is sup- plemented by the very slight dilation of the ring 28 SPRINGTIME SURGERY by the insertion of one finger, the danger from visceral prolapse is very remote. We have not observed the accident under these conditions. If the entire hand is forced through the ring, admittedly there is danger of prolapse. If the entire hand is forced through the fascia of the small oblique above and anterior to the internal ring or elsewhere in the vicinity, the inevitable rent will pass down, and involve, or pass along- side the ring and produce a tear essentially iden- tical with that caused by forcing the hand directly through the ring. Pathologic Testicles— Should the testicle fall within the second or third class we have men- tioned, and be greatly enlarged, so that it must be removed entire, it matters little whether the internal ring is enlarged to permit its escape or the same sized opening is made in close prox- imity to the ring. There results a great rent through which visceral prolapse is highly proba- ble. Should the operator know in advance that he has a testicle of extraordinary size to deal with, he should abandon the inguinal route and choose the upper flank as the safer and better. CASTRATION OF CRYPTORCHIDS 29 Indeed, under modern surgical technic, the flank operation is in any case quite as safe as the inguinal, whenever the operator inserts his hand into the peritoneal cavity. Should the testicle be in a pathologic state, and adherent to the intestines or other viscera, the flank operation is advisable or even necessary. In the one pathologic testicle removed in our clinics, the patient being a pig, the testicle was firmly adherent to two loops of small intestine. It was necessary to draw these out with the gland and dissect them away. In other animals than the horse, we con- stantly prefer the flank operation, except we can recognize the epididymis in the inguinal region, and draw the gland out by traction. Laparotomy.—For the flank operation, the patient is secured in lateral recumbency with the head end inclined, the flank shaved and dis- infected, and an incision is made as for flank spaying, of a size to admit one finger or the en- tire hand, according to the conditions. In small pigs and dogs and cats we have found the small wound sufficient. In large boars we 30 SPRINGTIME SURGERY have been forced to make the opening large enough to admit the hand. Inserting the index finger, or the entire hand, ’ the operator frequently recognizes the gland at once, lying just by the incision. Otherwise he reaches the inguinal ring, grasps the guberna- culum, glides along it to the epididymis, and thence to the testicle. Double Cryptorchids.—In double cryptor- chidism in small animals, both testes may be re- moved through one incision, or, having opened the wrong flank when but one gland is retained, he may still complete his operation through the erroneous incision. He merely needs pass his in- dex finger, or his hand, along the floor of the abdomen, across to the opposite inguinal ring, grasp the gland, draw it across to the other side and out through the incision. So, in the cryptorchid horse, if he is a double cryptorchid and the operator has inserted his en- tire hand in order to secure the first testicle, he should not make a second wound, but reach across beween the viscera and abdominal floor, seize the second testicle and remove it through CASTRATION OF CRYPTORCHIDS 31 the first wound. Likewise, in operating upon a horse with one abdominal testicle, where the scrotal testicle has been removed, and the opera- tor errs by cutting in upon the wrong side and has inserted his hand into the peritoneal cavity, he should not make a second wound, but remove the testicle through the wound already made. After Treatment.—After a cryptorchid tes- ticle has been withdrawn from the abdomen, the method of severing the cord is usually a minor matter. In our first class, which includes proba- bly ninety-nine per cent of the cases, and in which the gland has been arrested in its develop- ment, it is comparatively non-vascular and does not bleed. The completion of the operation may vary. In the flank operation, the abdominal wound is naturally sutured. If the inguinal operation has been cleanly accomplished with unimportant lac- eration of tissues and without danger of visceral prolapse, it may well be sutured. If there is danger of visceral prolapse or of serious infec- tion, antiseptic tampons should be inserted up to the internal ring, and held in position by sutures. 32 SPRINGTIME SURGERY By means of large tampons, an enormous rent in the abdominal floor may be successfully closed, and prolapse obviated. In large rents, the safest way to tamponade is to take a broad and ample piece of cheesecloth, and spread it with its center over the wound. Then take masses of convenient size of gauze, cheesecloth or cotton, boiled, im- mersed in a disinfectant and pressed dry, and push them in to the internal ring, inside the sheet of cheesecloth. No matter should it extend a few inches into the abdomen, it cannot escape. When the wound is well filled, the tampon is secured in place by scrotal sutures. After twenty-four to forty-eight hours, the sutures are to be removed, the packing inside the sheet of cheesecloth cautiously withdrawn, fol- lowed by the sheet of cheesecloth itself. Blood clots are then to be mopped out with antiseptic gauze, and, if deemed advisable, a new smaller tampon inserted for another day. According to the degree of infection, the wound may be let alone or mopped out daily with swabs of antiseptic gauze, preferably saturated with tincture of iodine. The inguinal wound should CASTRATION OF CRYPTORCHIDS 33 not be irrigated, lest the antiseptic be forced into the peritoneal cavity. Should fever arise, and not be promptly re- lieved by local handling of the wound, we recom- mend large doses of quinine or potassium iodide, usually ‘preferring the former. To a medium sized horse we give one to three ounces of quinine daily until the fever yields or toxic effects, such as trembling or diarrhea appear, when we change to potassium iodide. Mortality—This is not well known in crypt- orchid castration. In the ninety-one cases in our clinic there were included twenty-eight pigs, one dog and one cat, among which there were no losses. Of the sixty-one horses, fifty-six or ninety-two per cent recovered, and five animals or eight per cent died. These losses are abnormally high. Four of the five cases succumbed to infection. In the earlier years of our clinic, the opera- tions were essentially all by students. In many cases, six to ten different students each inserted his hand into the inguinal wound and palpated the parts. Three of the fatal infections resulted 34 SPRINGTIME SURGERY from this practice. This plan was then aban- doned, since which but one fatality has occurred from infection, following the operation by a mem- ber of the staff. Hospital Infection—In our clinic we have had another obstacle to meet. The late Professor Williams of Edinburg wrote more than a quarter of a century ago advising against the castration of horses when the wind was from the east, and to avoid operating in any kind of weather in the neighborhood of a veterinary college. Whatever may be effect of an east wind in England, the dangers of operating in a veteri- nary college are not to be ignored. Prior to the days of antiseptic and aseptic surgery, surgical operations on man in hospitals were followed by an appalling mortality, but the mortality from wound infections in hospitals for man have been very largely overcome. Veterinary surgery offers a different problem, especially in the horse, and the details of efficient asepsis and antisepsis in veterinary hospitals is not yet satisfactory. A prime difficulty in our work is cheapness in the construction and equip- CASTRATION OF CRYPTORCHIDS (85 Vv ment of our veterinary hospitals, with limited opportunity for efficient disinfection. From the beginning of our clinic in 1896 up to a recent date, we have noted an increased ten- dency toward serious infections, from the open- ing of the clinic in the autumn to its close in June. The hospital and operating room were then va- cant and open for the summer months. In other words, the presence in the hospital and in the operating room of cases of fistulous withers, poll- evil and other chronic, profusely suppurating maladies so befouled the establishment that viru- lent infection abounded. Our cryptorchid cas- trations came almost wholly toward the close of our school year, when infection of our hospital had apparently reached its highest virulence. This we have fought so energetically that we now believe we can perform most operations in our hospital with greater safety than outside, and be- lieve we can castrate as safely as anywhere. Neither do we observe increased infection as the year advances. In fact, we last year extended our clinic to cover the entire year, and are still able to keep wound infection under satsifactory control. 36 SPRINGTIME SURGERY Sources of Infection— Aside from the disin- fection of the instrument and of the hands, arms and clothing of the operator, there are other neg- lected sources of infection which the veterina- rian should recognize. Our casting apparatus constitutes a highly dangerous bearer of virulent infections, and the body surface of the animal, with its massive coat of hair, which it is perhaps shedding, affords ample opportunity for the entrance of infection into the wounds. We should devise better means for obviating these. Aside from infection, the mortality from crypt- orchid castration is well nigh negligible. Of course, casting accidents may occur, and some losses have taken place from intestinal prolapse. The latter, can and should, always be obviated. - Complications— Among our five deaths, one was due to an accident based upon an error. We opened the patient on the wrong side, recognized the vas deferens of the testicle which had been removed, but, before we were aware, had made a rent in its peritoneal fold. We reached across to the opposite side, grasped the testicle and re- CASTRATION OF CRYPTORCHIDS 37 moved it through the wound. A loop of the small intestine dropped through the peritoneal rent be- hind the vas deferens of the testicle which had been removed at a prior date, the intestine be- came strangulated and the patient succumbed. Had such a result been anticipated or thought of as a possibility all danger could have been obvi- ated, after the rent had been made, by rupturing the vas deferens, thus leaving no place for the incarceration of the viscera. So with other complications which may arise. The operator should preserve his equanimity, and, in cases of error or unexpected complica- tions, promptly and coolly meet the conditions. To this end, the operator needs be fully prepared for emergencies, have the surroundings in all es- sentials suitable, have abundant help at hand, and, beyond all else, needs be in good physical condition, free from fatigue of body or mind. In the one fatal error we have recorded, the difficulty was largely referable to the fact that the writer was ill, and should, by all rules of pro- fessional action, have been in bed instead of at the operating table. Good surgical work requires 38 SPRINGTIME SURGERY vigor of both mind and body, and we are forced to see this if we undertake an operation when we are unfit, and then meet with complications. Practical Methods of Cryptorchidectomy’ By Charles Frazier, B. Sc., M. D. V., Professor of Pathology and Bacteriology and Dean of the McKillip Veterinary College, Chicago It is my purpose in this article to outline a technic which has given uniform success in my hands, one that is based on a thorough study of the anatomical and surgical conditions met, and . one which I am sure any one can follow who has any skill whatsoever. I want at this point to em- phasize the fact that the operation, as practically carried out, is a simple one. Preparation of the Patient.— ‘This can be summarized in one statement. Have the patient’s bowels moderately full of ingesta and absolutely free from the irritability produced by cathartics, change of food and emptiness. Do not give *Reprinted from the American Journal of Veterinary Medicine, May, 1911. 40 SPRINGTIME SURGERY cathartics of any kind; do not starve the patient and do not upset the intestinal canal by a radical change of food. A bowel that is moderately distended with in- gesta, free from all forms of irritation, in nor- mal and perfect physical and physiological con- dition, is the one that is not going to be upset by any amount of clean manipulation in the abdo- men and surely is not the one to prolapse most frequently. Peritoneal irritabflity explains in a large degree prolapses of the omentum. The omentum has been aptly called the “policeman of the belly,” searching out, as it does, localized peritoneal disturbances, and through some power of its own going to such areas and attempting to cover them over by adhesions, where there is in- jury to or loss of the peritoneal tissue. Thus it is apt to wander down the inguinal canal at inop- portune times. Rectal Examination— Prior to the operation this is not to be thought of as a routine practice. In animals that have had one testicle removed and a diagnosis as to the side is wanted, there is a better way of proceeding than by rectal examina- PRACTICAL CRYPTORCHID CASTRATION 41 tion, and further, in such cases, a rectal exami- nation by the best operators gives no positive re- sults and frequently leads to harmful procedures. The question of the side upon which to operate is not, except very rarely, a difficult one to decide. The answer is obvious if the animal has never been operated upon or if one testicle has been removed and there is but one scar and that clearly upon one side of the scrotum. A diagno- sis is to be made, not at all upon the history the owner gives, but upon one’s own findings. This examination is to be made after the animal is cast, and consequently will be considered later. Disinfection— Antiseptic applications to the scrotum, prepuce and thighs, some hours preced- ing the operation, have no place in the technic. Theoretically they may be defended, but practi- cally they cannot. The total pre-operative treatment therefore consists of placing the patient upon a moderate diet for twenty-four to forty-eight hours preced- ing the operation. Nothing else is necessary, and other processes are not only superfluous but in- convenient to the general practitioner. 42 SPRINGTIME SURGERY The operation is carried out in as simple a rou- tine method as possible, keeping in mind at all times these three dangers, viz., casting accidents, prolapse of the bowels and infection. Equipment.— The necessary equipment for the operation consists of the following: A casting outfit, scalpel, emasculator and ecraseur, operat- ing sheets, green soap, tablets of bichloride of mercury, finger-nail brush, sterile, dry gauze packs in a sterile container, a trocar, a one-quart bottle, and a large needle and suturing material, preferably linen tape one-fourth inch broad. Casting — For the sake of uniformity of method all patients should be operated upon in the casting harness. The operating table offers no advantages and is not always at hand. The casting harness to use is the one that you are fa- miliar with, providing you are skilled in its use and can adapt it to the operation. Properly con- fining the animal is a larger question than the actual operation, since upon it depends, not only one’s success in satisfactorily performing the operation, but also the danger of casting acci- dents, and to a degree the dangers of prolapse of PRACTICAL CRYPTORCHID CASTRATION 43 the bowels and of peritoneal infection. The re- quirements of such a ‘harness are: 1. It must hold the animal firmly so that no change of position is possible. 2. All four legs and especially the hind legs must be fully flexed upon themselves and held so firmly that change of position is impossible. 3. The hind legs must be held by the harness in a widely abducted position with the legs so flexed that the hoof is just slightly in advance of the stifle. I cannot emphasize too strongly the impor- tance of this latter requirement. One should study and practice the art of casting until he is perfect in it; too many failures in surgical opera- tions are the direct result of bunglesome and im- perfect tying. The operating sheets mentioned in the list of articles needed for the operation have served me very valuable purposes and saved me much time and annoyance during operation. They are merely muslin sheets one and one-half yards square, some of which have central oval openings seven inches long by one inch wide. 44 SPRINGTIME SURGERY Plan of Procedure—The details of conduct- ing an operation in the country are about as fol- lows: Upon arriving at the place of operation a spot for casting is selected. There are no par- ticular specifications regarding a casting site ex- cept that it be level and of sufficient size. A grass plot is best, although not indispensable. A clean operation can be done anywhere, but more care is required in dirty, dusty surroundings. When the casting site is selected, the owner is directed to procure a pail of warm water and a basin and to have the patient brought out. While this is be- ing done the operator prepares his equipment for the operation. The scalpel, emasculator, ecras- eur and needle, threaded with a piece of tape fif- teen inches long, all previously sterilized by boil- ing, are laid out on a clean (if not sterile) towel on some improvised table, as a board, box or medicine case. The quart bottle is. filled with water and to it is added enough mercuric chloride tablets to make a solution of 1-1,000 or even 1-500. The can of sterile gauze, the nail brush, soap and operating sheets are placed conveniently near. The horse is then cast and tied, the opera- PRACTICAL CRYPTORCHID CASTRATION 45 tor (who, in country practice, must do the tying as a rule), wearing gloves to protect his hands to a certain degree from contamination. Chloro- form is not used. After the animal has been cast and properly tied for the operation, is the time to make the examination if a diagnosis of side is necessary. Of course, this is a question that needs attention only when one testicle has been removed and there is a scar on both sides of the scrotum. The side from which the testicle has been removed can be told in all cases by the presence of the stump of the cord or the spermatic fascia in the scrotum or inguinal canal of that side except in cases where the testicle removed was an abdom- inal testicle, when there will be no stump pres- ent. These cases are rarely met with, and a posi- tive diagnosis of the side can be made only by abdominal exploration during, the operation. Ordinarily when one testicle is removed it is a descended testicle and its removal leaves a stump in the scrotum and inguinal canal that can be easily determined by careful examination. The history by the owner is usually of no value and 46 SPRINGTIME SURGERY the character of the scrotal scar means nothing. As the operation proceeds the operator further satisfies himself as to his diagnosis as will be mentioned hereafter. A determination of the side having been made, the patient is placed in a position half way be- tween a lateral and dorsal decubitus, with the operative field uppermost. This is usually best accomplished by placing the horse in a lateral po- sition and then by means of a rope noose on the upper hock have an assistant apply a little trac- tion as if to roll the patient over on its back. This not only places the patient in a good position but abducts the upper limb and improves the con- dition of the operative field and thus facilitates the operation. Cleansing the Field of Operation.—The next question for the operator to concern himself with is that of the aseptic preparation of the opera- tive field. An appreciative mind will understand that all the dangers of this, as well as any other surgical operation, are increased by prolonging the period of the operation. Consequently the period from the time the casting harness is put PRACTICAL CRYPTORCHID CASTRATION 47 on the patient until the animal is again up and in its stall should be as short as is consistent with good surgical principles. The process of asepti- cizing the operative field is one in which much time can be saved by a study of the conditions. Excessive scrubbing and cleansing is not only without results of value but often productive of conditions exactly opposite to those at the pro- duction of which the process is aimed. Absolute asepsis can not be obtained in veterinary practice except at a great outlay of expense and trouble that is not justifiable. In cryptorchid operations relative asepsis is all that is needed for success- ful work. Peritoneal infection and scrotal infec- tion are the least of my fears when operating. A good rule is to be as aseptic as the conditions will allow without endangering your patient by a prolonged, bunglesome technic (and without los- ing money on the operation). The method that I follow in country work in preparing the operative field requires from two to five minutes, the length of time consumed depend- ing on whether it is done by myself or by an as- sistant while I am scrubbing my hands. The 48 SPRINGTIME SURGERY process consists of scrubbing the scrotal area only, with green soap and water until it is free from visible dirt. The upper foot, leg and thigh are then encased in an operating sheet which is clean (not sterile) and which is applied in a few seconds of time, being made so as to fit the parts and supplied with proper means of attachments. This protects the field against serious contamina- tion from that source. The lower leg may be covered in a like manner, but this.is rarely neces- sary. The soap and water scrubbing is confined to a small area of the scrotum at the point where the incision is to be made. This is important. Uncleaned areas near the field of operation are covered by a sheet and are just as removed from the operation as if they were on another animal. The soap and water scrubbing over, and the two hind legs encased in protective sheets, the operator proceeds to scrub his hands and arms, . paying particular attention to the hand that is to be inserted into the belly wall. Relative asepsis only is aimed at by a one- to three-minute scrub- bing of the hands with the brush and green soap, followed by a short scrub in the bichloride solu- PRACTICAL CRYPTORCHID CASTRATION 49 tion. This being done, the operator with clean hands gives a short final scrub to the operative field which is then subjected to an application of the bichloride solution and an operative sheet spread over the belly and scrotal region so that the opening comes over the line where the in- cision is to be made. The area of the incision is then painted with tincture of iodine, a quick, practical and efficient means of producing sur- face asepsis. The Incision— The routes by which the ab- dominal cavity is entered by cryptorchid cas- trators may be clased into three general groups, viz.: 1. Through the inguinal canal. 2. Directly through the belly wall in the neigh- borhood of the internal ring. 3. Directly through the belly wall in the upper flank region. There are a number of varieties of each group, each of the numerous operators varying the process to suit his individual taste. The method that I prefer is the inguinal canal route. The technic of entering the abdominal 50 SPRINGTIME SURGERY cavity by this route is as follows: An incision, five or six inches long, is made through the scrotum parallel with and one or two inches from the median raphe. This incision is carried through the skin and dartos into the scrotal sac. When this is done the scalpel is laid aside and the remainder of the process is carried out entirely by blunt dissection with the fingers. The scro- tum is found to contain considerable areolar fascia and a mass of blood and lymph vessels. No attention is paid to these; they are pulled this way or that, until an opening is made through them down to the external ring of the inguinal canal, which is but an oval slit through the apo- neurosis of the external oblique muscle, large enough to freely to admit the operator’s hand. This muscle is located just in front of the pubis and at the side of the prepubian tendon, land- marks that are easily determined. The exposure of this ring and the introduction of the hand into it is a matter of no difficulty. The fingers of both hands are used in the dissection up to this point. Now but one hand is required to finish the opening. PRACTICAL CRYPTORCHID CASTRATION 51 Traversing the Inguinal Canal. The oper- ator places himself so that he is facing the field of operation and uses the right hand if it is the left testicle that is retained and vice versa. The hand used is inserted through the scrotal incision and through the external inguinal ring into the inguinal canal. The fingers of the hand should be bunched and directed toward the internal in- guinal ring, to which they are gradually forced, separating the muscular belly of the internal ob- lique muscle, which lies on the palm or side of the hand, from the aponeurosis of the external oblique muscle and Poupart’s ligament which lies on the back of the hand. While the introduc- tion of the hand through the external ring and into the canal is always an easy matter, the pass- ing of the hand up the canal in the proper direc- tion and the locating of the internal ring is, to the uninitiated, usually attended with more or less difficulty. The direction to go is deep into the fold of the groin, keeping back against Poupart’s ligament and the thigh muscles. Most beginners, I have found, have trouble in locating the internal ring because of two chief 52 SPRINGTIME SURGERY mistakes. One is in keeping too far forward and the other is in being afraid to insert the hand far enough up the canal. I therefore try to empha- size the importance of going high up into the groin and keeping back against the thigh when forcing the hand up the canal. Locating the [Internal Inguinal Ring.—. After the canal has been traversed by the hand the selection of a spot for the opening into the belly is the next thing of importance. There are four places that may be used and are used by various operators. 1. Through the internal ring. 2. Below the internal ring. 3. In front of the internal ring. 4, Above the internal ring. No matter what position is selected for the opening, the wise operator will first locate the in- ternal inguinal ring as a starting point. This ring represents the upper end of the inguinal canal. After the hand has been forced up the canal to a point beyond the upper border of the internal oblique muscle the operator finds that only a relatively thin structure separates his PRACTICAL CRYPTORCHID CASTRATION 53 fingers from the abdominal viscera, which can be felt more or less clearly. This thin membrane consists of two chief parts or layers. These are, first, the general fascial lining of the abdomen, which is often designated as the transversalis fascia and is spread out as a lining of the entire abdomen and pelvis, and, second, the peritoneum. In the animal with the testicle undescended the internal ring is not an opening or a slit as it is sometimes said to be but it is merely a thinned- out area of the above mentioned transver- salis fascia, this area being bordered and limited in front and below by an arched band of con- nective tissue which, after the descent of the testicle through the fascia at this point, forms the true ring. The upper and posterior borders of the thinned-out area of the fascia have no limiting band of fibers and, as a matter of fact, in the ridgling the area is not defined at all in these two directions. (The anatomical facts may be beautifully demonstrated by a dissection of a seven or eight-months’ fetus.) Consequently, the operator, in searching for the internal ring, does not feel for a slit-like opening, but searches for a 54 SPRINGTIME SURGERY thin portion of the membrane which presents an arched, limiting band of fibers in front and below. This band may often be demonstrated externally by deep palpation in the middle of the fold of the groin. Its determination with the hand in the canal is a matter of little difficulty. In a great many cryptorchids the testicle or epididymis has partially descended through this area and one may find a condition of affairs vary- ing from a mere looseness of the fascia in the area to a finger-like projection of it containing the tail or more of the epididymis. Ofttimes the tail of the epididymis has descended through this area and the band of fibers, which normally con- tracts after natural descent of the testicle, has contracted down, constricting the testicular struc- tures so that the globus minor of the testicle is below the band and the globus major and the body of the testicle is above and within the ab- dominal cavity and unable to descend further. The internal ring, or better, this area in the transversalis fascia, lies just anterior to the shaft of the ilium at about its middle and the fascia just behind the ring is reflected backward into the PRACTICAL CRYPTORCHID CASTRATION 56 pelvis where it becomes the pelvic fascia and where it is more or less firmly anchored. I, there- fore, often consider the internal ring in the ridg- ling as being a thin area in the transversalis fascia bordered anteriorly and inferiorly by this arched band of fibers and posteriorly and supe- riorly by the shaft of the ilium, around which the fascia is reflected into the pelvis and to which it is more or less intimately attached. This area as de- fined is just about large enough to admit a hand with ease. The recognition and protection of the integrity of the borders of this internal ring is a matter of much importance in the operation. In the process of passing the hand up the canal and in locating the internal ring, the operator may inform himself concerning a number of _ things. If it is a second operation he may ob- serve by the scar tissue how far up the inguinal canal the previous operator went and where and whether or not he entered the abdominal cavity. If a diagnosis of side has been made, the operator while in the canal confirms it by the absence of the cord stump in the canal. One, of course, ob- serves whether or not the testicle or any part of 56 SPRINGTIME SURGERY it has descended into the canal, producing a com- plete or partial flanker. If it is a complete flanker, all of the testicle having passed through the inner ring, the case is handled as a plain colt. If only a part of the testicle is descended, ignore the condition and operate as a ridgling, making the opening at the usual point. In the partially descended testicle it is almost always the tail of the epididymis that has descended and the ring has contracted down around it so that the testicle cannot pass through and usually cannot be pulled through with safety to the ring. I have found that these are best handled by passing up along the side of the descended tail and, making the opening at the usual place, pulling the descended portion back into the belly and out the opening. Opening the Peritoneal Cavity— I have satisfied myself that the best place to open into the peritoneal cavity from the upper end of the canal is at a point just in front of the shaft of the ilium, at the upper part of the internal in- guinal ring. In operating, I locate the internal ring and then proceed upward and somewhat backward until I come to the point where the PRACTICAL CRYPTORCHID CASTRATION 57 fascia passes back into the pelvis and here I thrust two fingers through into the belly cavity. In making the opening one must remember that there are two layers to go through, the fascia and the peritoneum. Sometimes the peritoneum pushes ahead of the fingers and strips off of the wall and requires a special effort to puncture. This is particularly true in older horses and in second operations where age and inflammation have thickened and toughened the peritoneum. It is also more apt to occur in the horses with empty intestinal tracts. Before leaving the subject of the opening into the belly I wish to emphasize one thing. Preserve the integrity of the band of fibers that bounds the internal ring anteriorly and inferiorly. This band is not easily torn, but in the use of force in extracting the testicle or in other manipulations, see to it that no great tension is thrown upon it. So long as this band is intact the rent in the fascia is limited by it. If it is torn across, any increase in the intra-abdominal pressure may cause it to tear farther down and the protection against pro- lapse of the bowel is lost. In all cases where an 58 SPRINGTIME SURGERY enlargement of the opening is necessary make it upward and backward; never by use of the knife or other means enlarge the opening in the other directions. If one finds a testicle so large that it cannot be forced out through this area with- out endangering this band of fibers, then it is too large a testicle to be removed through the in- guinal region. This is too dependent a portion of the belly wall for large openings at any point. My method of handling such cases, which fortu- nately are very rare, is, if the testicle cannot be forced through the opening after all means of reducing its size (tapping of cysts, etc.) have failed, to discontinue the operation at this point, allow the inguinal wound to heal, and after three or four weeks remove the testicle through a lapa- rotomy in the upper flank region. Locating the Testicle— We will presume that the operator has traversed the inguinal canal, located the internal ring area, and advanced be- yond this area in a direction upward and backward until he finds his fingers against the pelvic inlet at the middle of the shaft of the ilium, and at this point has thrust two fingers through the medium PRACTICAL CRYPTORCHID CASTRATION 59 separating his hand from the peritoneal cavity. With the same movement by which the opening is made, it should be enlarged to a size sufficient to admit three fingers, by the spreading of the two fingers that have been used. If this is carried out quickly and if the rent made is held open by the two fingers and at the same time the hand is retracted somewhat so as to make an empty space in the upper end of the canal, the testicle or some part of its cord will be forced out into the palm of the hand. This will occur in a very large per- centage of the cases, in all that are not compli- cated by adhesions or grossly pathological testicles. This little process of “coaxing” the testicle out is possible only when the animal is properly tied, when the opening is properly located, when the abdomen is not too empty, and there is an intra- abdominal pressure, and when the animal is not anesthetized. To the beginner, with some doubt as to his ability, there is no more pleasant sensa- tion than that produced by the testicle forcing itself upon him and down the canal. If the “coaxing” process fails in its purpose after a few seconds’ trial, then the fingers explore 60 SPRINGTIME SURGERY the region inside the opening. The cord -struc- tures pass from above downward in close juxta- position to the opening. They are attached to the belly wall near the opening and consequently can- not get far away. More often they are right be- neath the finger tips, very often they are in front of the opening and less frequently they are be- hind the opening. In the past six years with a large series of cases it has not been necessary for me to introduce the entire hand into the abdomen to locate the testicular structures. I have, in several cases, introduced the hand into the abdo- men for the purpose of examining pathological and enlarged testicles, and for overcoming cer- tain conditions in the removal of testicles. No Search Necessary.— With due attention to the entrance into the abdomen, search for the tes- ticle is eliminated. It is right at the finger tips when they are introduced. The only thing that is necessary is to be able to recognize the differ- ence, by sense of touch, between the testicular structures and loops of bowel. This should not be difficult, but I notice that some are unable to do it with certainty. Examination of the structures PRACTICAL CRYPTORCHID CASTRATION 61 that present themselves to the fingers will soon reward the operator by a discovery of the cord or testicular parts. If in doubt, bring the structure down the canal and examine it by the sense of sight. Remember that some of the structures wanted are just inside the opening and that a little patience will reveal them. The time-worn quack story about going up to the diaphragm and the spine to find the testicle is to be forgotten. It is for the edification of the laity only. I have never found it of value to use the gubernaculum as a guide in finding the testi- cle. Some parts of the epididymis, cord or testicle presents itself invariably upon entering the peri- toneal cavity, and rarely indeed is the slightest search required. Removal of the Testicle—The testicular structures having been located and recognized, they are brought down the canal and removed. This is usually an easy matter. The testicle and epididymis are drawn down by the fingers until an emasculator can be applied. It is well to have at hand an ecraseur to use in case the cord struc- tures are so short that the testicle cannot be 62 SPRINGTIME SURGERY drawn far enough down to use the emasculator. One can use an ecraseur in all cases and dispense with the emasculator altogether, but I have found that an emasculator can be used in about ninety per cent of the cases and, being a much quicker and easier method than the other, one is justified in carrying both instruments in his equipment. In cutting off the testicle see that the three parts are removed, viz., body of the testicle, head of the epididymis and tail of the epididymis. These three parts are often far separated in a retained testicle and it is well to see that they are all in- cluded in the parts removed. “Cutting "Em Proud” a Fake.—I might say in this connection, that the old idea that leaving on the stump of the cord, a part of the epididymis would influence the nervous and physical develop- ment of the animal and give to it the characteris- tics of a stallion cannot be substantiated. The influence that the testicles have upon the physi- cal and temperamental development of the ani- mal depends upon an internal secretion elabo- rated by these organs, absorbed into the blood and lymph channels and exerting its influence, in PRACTICAL CRYPTORCHID CASTRATION 638 harmonious relation to other internal secretions, upon the activity and metabolism of the various systems of organs. This internal secretion is elaborated largely if not entirely by groups of epithelial cells embedded in the stroma of the body of the testicle and not found in any part of the epididymis. I have satisfied myself on the proposition by leaving the epididymis in a few castrated animals with negative effect. Complications That May Exist. — Occasion- ally more or less difficulty is met with in bringing the testicle through the opening and down the canal. When one has located the cord and moder- ate traction on it fails to bring the testicle into the canal it is due to one of the following causes: 1. An enlarged testicle, which hangs heavily over the border of the ring. 2. A partially descended testicle, the tail of which is gripped by the contracted ring (this, of course, should have been recognized previously). 3. Adhesions of the testicle to the abdominal wall at some point. In the presence of any of these complications the first thing to do is to examine and diagnose 64 SPRINGTIME SURGERY the complicating conditions. The cord which has been grasped and pulled down into the canal is held by the fingers of the free hand or by a pair of heavy forceps. The hand in the canal is then passed up along the cord and with the fingers, or if need be the entire hand, in the peritoneal cavity the structures are examined, remembering that the testicle is attached to the lower end of the doubled cord in the inguinal canal and that by fol- lowing this out the testicle will be reached. Oc- casionally it may be best to turn the cord loose, especially if the entire hand is inserted into the abdomen. . Cases of these kinds are fortunately rare and when one is met a little patience on the part of the operator will allow him to make a positive diagnosis of the complicating condition. The treatment of adherent testicles is obvious. The adhesions are broken up and the testicle brought down. In the cases in which the tail of the epididymis has descended through the internal ring and is in the grasp of the ring the treatment consists in pulling it back into the belly and out through the opening and down the canal. The handling of enlarged testicles is a subject of more PRACTICAL CRYPTORCHID CASTRATION 65 importance. From a practical standpoint the en- larged testicles may be divided into two classes, viz., cystic and solid, the former admitting of a reduction in size by tapping. Upon the discovery of an enlarged testicle during the progress of the operation the operator settles two questions in his mind. First, is the testicle small enough to pass out through the ring safely? This, however, varies greatly in different cases and the operator is the judge of the possibilities in a given case. Second, is the testicle cystic? If so, it is tapped through the inguinal canal with a long trocar. The technic is as follows: An assistant, not necessarily but best a skilled assistant, empties the rectum of the patient and inserts the hand into the same as far forward as possible. By the direc- tions and assistance of the operator, the assistant, by rectal manipulation, pushes the testicle up against the internal ring and holds it there firmly by pressure from behind. The operator then in- serts a trocar up the canal, and it is usually an easy matter to draw off the cystic fluid. The rectal manipulation of an assistant is of great value also in the withdrawal of a large testicle 66 ' §PRINGTIME SURGERY through the internal ring. Where the mass is so large that there is difficulty and danger in pulling it through the ring by traction on the cord alone, then an assistant working through the rectum can be of great assistance. He can force the testicle through the ring in a manner that is much safer than that of pulling it through and much larger testicles can be removed safely by such means than can be removed by pulling alone. Laparotomy May Be Necessary.If the ex- amination or repeated trials demonstrates the fact that the testicle is too large to be safely re- moved through the inguinal canal and its size can- not be reduced by tapping or other means, then there is but one thing to do. Discontinue the at- tempts at removal, dress the wound, allow the patient to rise, and wait a couple of weeks until the inguinal wound is healed and then take the testicle out through a laparotomy opening in the upper flank. One might argue at this point that a rectal exploration preceding the attempted oper- ation would have made unnecessary the exposure of the patient to the dangers attending the"abdom- inal exploration, but this is not true. I have yet PRACTICAL CRYPTORCHID CASTRATION 67 to see the man who is positive enough in his find- ings by rectal examination to gamble on his diag- nosis. Abdominal exploration is certain in its re- sults and the dangers are practically nil when one practices good technic. The tapping of cystic testicles is not attended by any danger. The contents of these cysts is sterile and leakage into the peritoneal cavity is of no consequence. I remember of but one report in the literature of an infected testicular cyst. They are so rare as to be of negligible import. Wound Treatment —After the testicle has been disposed of. The dressing of the wound is to be undertaken. This is simple. It is best explained by emphasizing a few things that it is important not to do. Do not, at any time, introduce any kind of anti- septic or aseptic fluids into the inguinal caual. From the time the operator takes his scalpel to make the scrotal incision until the operation is completed, clean methods are important, but anti- septic solutions within the abdomen are tabooed. Do not at the end of the operation remove the blood from the wound. There is no hemorrhage 68 SPRINGTIME SURGERY of any consequence and it is seldom that one needs to ligate a bleeding point. The only hemorrhage that one can have is from the vessels of the dartos and they are small. Hemorrhages from the stump of the cord is practically unimportant except oc- casionally in pathological testes, in which case one can ligate before cutting off with the crushing in- struments. Do not introduce a pack of any size into the inguinal canal. I believe that any operation that requires the canal to be packed is, generally speak- ing, a failure. Operating by the foregoing method, heeding the warnings that have been given, one will never have need for the pack. The opening into the belly that is described in the foregoing is a self-protecting one against es- cape of the viscera. Of course, it is possible for a loop of bowel to come down, but I have never had such to occur.